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insurance application form 1. Your personal details You can complete the CareSuper member number Date of birth (DD/MM/YYYY) insurance application process online via the Insurance section of MemberOnline at caresuper.com.au Instructions To apply to change your State/Territory Postcode occupational category, complete sections 1, 2 and 9e, and ensure you read Telephone (home) sections 9a and 9b.
To apply for a New Member Option (Employee Plan members only), complete sections 1, 2, 3, 4 and 9.
To apply for tailored cover, complete sections 1, 2, 5, 6 and 9 and follow all instructions. If you wish to opt out or reduce your level of default cover, please call the CareSuperLine Duties performed Gross salary or remuneration earned in the last 12 months on 1300 360 149. Please do not complete this form.
Please complete the 2. Occupational categories form in blue or black pen and BLOCK letters. CareSuper offers three different categories of cover to reflect the different levels of risk associated with our members' occupations. Please complete the following questions to determine the category that applies to you: Determine the category 1. Are the duties of your occupation limited to professional, managerial, administrative, that applies to you. clerical, secretarial or similar ‘white collar' tasks which do not involve manual work This will determine and are undertaken entirely within an office environment (excluding travel time from your premiums and the one office environment to another)? unit-based cover amount 2. Are you earning in excess of $80,000 per year from your profession? that will apply to you. (Please see the Insurance Guide at caresuper.com.au/PDS for a definition of ‘earnings')3. a) Do you hold a tertiary qualification, or are you a member of a professional institute or registered by a government body? b) Are you in a management role? If you answered no to all of the questions, you qualify for the General occupational category.
If you answered yes to Q1 you qualify for the Office occupational category.
If you answered yes to Q1 and Q2, and to either Q3a or Q3b, you qualify for the Professional occupational category.
• Your level of cover will be reviewed each time you complete a new application form or apply to vary your insurance cover.
• If you are a new member and you do not complete this section, the General category will apply to your cover.
3. New Member Options – available in your first 90 days (for Employee Plan members only) You are an Employee Plan member if your employer Increase your death and TPD cover or add income protection cover with no health assessment provided you are under pays super guarantee age 60 and your application is received within 90 days of the date on your Welcome letter or email. Please choose your contributions on your behalf. option by ticking (✓) your choice(s).
You are a Personal Plan I would like to increase my total death and TPD cover up to 7 times my salary (maximum limit of $750,000). member if you are responsible Refer to the Insurance Guide for the full definition of salary.
for paying your own super. My annual gross salary (including overtime, commission, bonuses and Personal Plan members do shift allowances but excluding mandated SG contributions) is: not need to complete section 3 of this form.
I want my total amount of cover to be: Death $ Please choose a New I would like this cover to be: Unit-based OR Member Option by ticking I would like to index my fixed cover annually by 5% (✓) your choice(s) if desired.
I would like to add income protection cover. Please complete section 4 on page 2.
* Under New Member Options, TPD cover must be less than or equal to death cover.
* Under New Member Options, cover is subject to a pre-existing condition exclusion. You cannot make a claim for illness or injury relating to pre-existing conditions that occurred during the 5 years before your application for the increased cover. Please see the Insurance Guide for details. See over > Do NOT detach form CARE Super Pty Ltd (Trustee) ABN 91 006 670 060 AFSL 235226. CARE Super (Fund) ABN 98 172 275 725 CR/SUP/INS/APP/710.1 05/16 ISS8 4. Income protection Income protection cover provides a temporary To be eligible for income replacement income if protection cover, you must you are unable to work due If you are in the General be aged under 65 and: to illness or injury (specific occupational category, cover in $6,001 – 12,000 excess of 12 units of cover is conditions apply). Be earning at least $12,001 – 18,000 subject to insurer assessment. $16,000 per year on Please complete sections If your annual income $18,001 – 24,000 an ongoing basis, or exceeds the maximum cover $24,001 – 30,000 Working 15 hours or amount for your occupational $30,001 – 36,000 more per week.
category and you wish to apply for cover at this level, $36,001 – 42,000 you will need to also $42,001 – 48,000 complete section 6 – the $48,001 – 54,000 Personal health statement.
$54,001 – 60,000 $60,001 – 66,000 Your annual income* $66,001 – 72,000 If you apply for income (including overtime, protection as a New Member commission, bonuses $72,001 – 78,000 If you are in the Office occupational category, cover in Option within 90 days of the and shift allowances) is: $78,001 – 84,000 excess of 17 units of cover is date on your Welcome letter $84,001 – 90,000 subject to insurer assessment. or email, no evidence of Please complete sections $90,001 – 96,000 health is required. *Refer to the Insurance $96,001 – 102,000 Depending on your Guide for the definition $102,001 – 108,000 If you are in the Professional occupational category, the occupational category, cover in maximum levels of cover $108,001 – 114,000 excess of 24 units of cover is shown will apply: $114,001 – 120,000 subject to insurer assessment. If your income is less than Please complete sections 6, 7 and General: Maximum cover $16,000 p.a. you can $120,001 – 126,000 without health evidence still be eligible for income $126,001 – 132,000 protection cover if you work $132,001 – 138,000 Office: Maximum cover 15 hours or more per week. $138,001 – 144,000 without health evidence Please tick (✔) this box if this applies to you. Cover subject to insurer assessment and may be limited Professional: Maximum by maximum benefit provisions, cover without health evidence as detailed in the insurance policy. Please complete sections 6, 7 and 8.
Benefit periodPlease indicate the benefit period you would like. A 2-year benefit period will apply if you do not make a selection.
Waiting period Please indicate by ticking (✔) the waiting period you would like to select (refer to the Insurance Guide for details). The 30-day waiting period will apply if you do not make a selection.
Note: If you wish to reduce the waiting period in the future you will need to complete a new application form, including the Personal health statement.
This section is for members 5. Tailor your insurance who are applying for cover outside of the New Member Death and TPD cover Options. An application to You can apply for unit-based cover or fixed cover, or a combination of both. You can have more TPD cover than death cover. increase your insurance Note: When you make an application for tailored cover it will automatically replace any cover held, so when applying for tailored cover please ensure that you nominate the total amount of cover you require. If your application is cover requires a health declined, your prior cover will continue.
assessment and is subject Please enter the amounts of cover you require below, and tick (✔) further options as appropriate: to the insurer's approval.
Death and TPD cover Death and TPD cover I would like to index my fixed cover annually by 5%.
Income protectionRefer to the Insurance Guide to calculate the number of units you want, up to 85% of income. If your annual salary exceeds $423,530, your income protection cover will be subject to maximum benefit restrictions. I would like to apply for units of income protection cover.
2 years (default) 30 days (default) Your annual income* (including overtime, commission, bonuses and shift allowances) is $ * Refer to the Insurance Guide for the definition of income.
See over > CARE Super Pty Ltd (Trustee) ABN 91 006 670 060 AFSL 235226. CARE Super (Fund) ABN 98 172 275 725 6. Personal health statement This information will be treated in strict confidence and will be used or disclosed only for matters relating to your insurance entitlements. If this section is not completed the insurer will be unable to process your insurance application and your requested level of insurance cover may be denied. You must complete ALL questions.
1. If you have applied for Honesty statement a New Member Option in section 3 or 4, you You are applying to enter into a contract of insurance.
As such, you have a duty to disclose all relevant information. Failing to provide the insurer with full and accurate complete section 6 information could result in your insurance cover being cancelled and any claim for benefits could be denied, so it is vital unless you are applying you answer all questions fully and accurately.
for income protection cover greater than the Although we ask you specific questions via a personal statement, you should also tell us about any other information that amount available will impact on the insurer's decision to offer you insurance cover, regardless of whether you deem it to be material or without evidence of important. This includes current medical issues that require investigation, medication or treatment, even if a diagnosis health. Go to section 9 has not been made.
and sign and date the This obligation applies to all insurance cover relating to this application, including amounts transferred from another fund application form.
or insurance arrangement. This means you could be placed in a position where you have no insurance cover if we later 2. If you are applying for find you have not answered all questions fully and accurately.
tailored insurance Your duty of disclosure continues until you receive written confirmation your application has been accepted. You must contact the insurer if there is any change in your health or circumstances that are relevant to the insurer's decision on complete section 6.
The full Duty of Disclosure is contained within this document and it is important you read it carefully. Having read the above, I declare the information I am about to provide is honest, true and complete.
Member's signature Date (DD/MM/YYYY) 1. What is your: Height 2. Have you smoked tobacco, e-cigarettes or any other substance in the last 12 months? If ‘yes', please indicate what you smoke What is your average? 3. Do you drink alcohol? If ‘yes', please provide the average number of standard drinks consumed: Do NOT detach form See over > CARE Super Pty Ltd (Trustee) ABN 91 006 670 060 AFSL 235226. CARE Super (Fund) ABN 98 172 275 725 CR/SUP/INS/APP/710.1 05/16 ISS8 6b. Personal statement details Please tick (✓) Yes or 1. Do you engage in any hazardous pastimes or pursuits such as, but not limited to, football (other than Tick (✔) No or Yes touch or Oztag), motorised sports, parachuting, hang-gliding, abseiling, mountaineering activities, No for each question.
aviation (other than a fare paying passenger), scuba diving or any sport(s) in a professional capacity? a) Recently applied for or do you have a policy for life, total and permanent disability, trauma or salary continuance (excluding this application)? b) Ever had an application for life, disability, trauma, accident or sickness insurance on your life declined, deferred or accepted with a loading, exclusion or special terms? c) Ever claimed a lump sum or accident or sickness benefit from any insurance policy, including but not limited to superannuation, workers' compensation, disability pension or Veterans Affairs? 3. Have you ever experienced symptoms, received medical advice, been treated for or diagnosed with any back, neck, hip, shoulder, knee or elbow complaints, sciatica, disc or spine complaints, or an injury, complaint or disorder of any joint, bones or muscle, including arthritis, gout or repetitive strain injury (RSI)? 4. Have you ever received medical advice, been treated for or diagnosed with depression or a mental illness, including but not limited to stress, anxiety, chronic tiredness or lethargy, panic attacks, post traumatic stress, behavioural or nervous disorder, attention deficit disorder or aspergers syndrome, myalgia or fibromyalgia or Chronic Fatigue Syndrome? 5. Have you received medical advice, undergone any treatment, investigation or operation for, or had: a) High blood pressure or raised cholesterol? b) Cyst, mole, sunspots, skin lesions, skin cancer or melanoma? c) Asthma (other than childhood), chronic bronchitis, emphysema, recurrent pneumonia or any other lung complaint requiring hospitalisation? d) Chest pain, heart complaint, cardiomyopathy, stroke, neurological disorder, multiple sclerosis, muscular dystrophy or blood disorder? e) Cancer, leukaemia, diabetes or chronic kidney complaint? a) Taken any illegal or non-prescribed drugs (other than off the shelf medications) in the last 10 years? b) Ever been advised to cease drinking alcohol or received counselling or treatment for alcohol or substance abuse? c) Ever been infected with or tested positive for HIV/AIDS, Hepatitis B and/or C or are you awaiting the results of such a test? d) In the last 5 years, ever engaged in unprotected anal sexual intercourse (except in a relationship between you and one other person only where that person is not known or suspected to be HIV positive and/or injects non-prescribed drugs) or worked as or engaged the services of a prostitute? 7. Apart from anything already stated: a) Are you considering seeking medical advice, treatment, tests or surgery in the future? b) Have you, in the last 5 years, received any medical advice, any medical treatment, investigation or had any operation not mentioned above (apart from colds, flu, contraceptive advice)? 8. To the best of your knowledge, have any of your natural parents, brothers or sisters suffered from or been diagnosed with:a) Heart or circulatory problems, stroke, high blood pressure, diabetes? b) Depression or any other mental illness? c) Cancer of any type? d) Huntington's disease, muscular dystrophy, multiple sclerosis, polycystic kidney disease or any other hereditary disease? 9. a) In the next 12 months do you plan to travel to another country? b) In the last 6 months have you been in another country? If ‘yes' to either or both question(s), please provide details below: Date of departure from Australia (if applicable) arrival in Australia Reason for travel Have you answered ‘yes' to any questions in section 6b?No > Go straight to section 9 on page 11. Do not complete section 7 or 8.
Yes > For each ‘yes' answer you must complete a corresponding questionnaire, as noted in the column beside your ‘yes' answer above. Proceed to relevant questionnaire in section 7 on pages 5-9. * If you have answered ‘yes' to question 6, a confidential questionnaire will be sent to you.
See over > CARE Super Pty Ltd (Trustee) ABN 91 006 670 060 AFSL 235226. CARE Super (Fund) ABN 98 172 275 725 7. Questionnaires Only complete if you answered ‘yes' to Questionnaire A – Pastimes questionnaire Tick (✔) no or yes question 1 of section 1. Do you engage in any of the following hazardous pastimes or pursuits? a) Flying? (other than as a fare paying passenger on a commercial airline) statement details.
b) Underwater diving (scuba) If ‘yes' (i) do you dive more than 40 metres in depth? (ii) do you dive alone? c) Football of any code (other than touch or Oztag) d) Motorised sports of any kind, e.g. motor cross, rally driving, ocean racing, motor car or bike racing e) Trail bike or quad bike riding (including off road and dirt bike) f) Any other sport or hazardous activity, e.g. parachuting, hang-gliding, body contact sports, para-gliding, competitive water sports, horse riding or recreations involving heights? If you have answered ‘yes' to any of the above questions, please answer the following questions: What are the activity(ies) you engage in? At what level do you participate? (tick (✔) the appropriate box) Recreational only (non competition) Recreational with competition Number of times you participate on average in this activity(ies) per year, e.g. hours flown, number of dives, events? Do you receive income from participating in this activity(ies)? Questionnaire B – Insurance history questionnaire Only complete if you 1. Other than this application, do you have or have you recently applied for life, total and answered ‘yes' to any permanent disability, trauma, or salary continuance on your life with CommInsure, or any part of question 2 of other insurance company? section 6b – Personal statement details.
If ‘yes', please provide details below: Insurance company Insurance benefit 2. Has an application for life, total and permanent disability, trauma, or salary continuance on your life ever been declined, deferred or accepted with a loading, exclusion or special terms? If ‘yes', please provide details below: Insurance company When was the decision made on the application? Terms offered and reason 3. Are you claiming or have you ever claimed a benefit from any source, e.g. TPD benefit, from any superannuation fund, Workers' Compensation, Disability Pension, Veterans' Affairs or any other insurance policy providing accident or sickness benefits? If ‘yes', please provide details below: Benefit type/source/reason for claim See over > Do NOT detach form CARE Super Pty Ltd (Trustee) ABN 91 006 670 060 AFSL 235226. CARE Super (Fund) ABN 98 172 275 725 CR/SUP/INS/APP/710.1 05/16 ISS8 7. Questionnaires (continued) Questionnaire C – Joint/musculoskeletal Questionnaire D – Mental health Only complete if you answered ‘yes' to question 3 of 6b Only complete if you answered ‘yes' to question 4 of 6b – Personal statement details.
– Personal statement details.
1. Nature of complaint (doctor's diagnosis), e.g. sciatica, 1. Please provide details of the condition (doctor's diagnosis): back pain, broken bone.
2. Please indicate the reason or cause by ticking (✔) the 2. Location of complaint, e.g. lower back, right knee, appropriate box(es): sciatic nerve.
Bereavement/family illness Marital problems 3. When did symptoms first begin? Other (please specify) 4. Cause of condition, e.g. lifting, car accident, fall in workplace, unknown.
3. Date symptoms first commenced: 5. Was an x-ray or scan taken? 4. Have the symptoms ceased? If ‘yes', please complete the details below: If ‘yes', please provide the date symptoms ceased: Date of most recent test Details of results of tests taken: 5. Have you taken or are you taking medication? If ‘yes', please provide details 6. Is the nature of the condition degenerative or a disc problem? 7. Are you still undergoing treatment or experiencing symptoms? If ‘no', please complete the details below: Date symptoms ceased 6. Have you attempted suicide or had suicidal thoughts? Date treatment ceased 7. Have you ever been hospitalised? 8. Have you been off work as a result of this complaint or been unable to perform If ‘yes', please indicate period(s) hospitalised: your normal day to day activities? No Yes If ‘yes', please indicate period(s) off work: 8. Did the condition ever cause you to take time off work? If ‘yes', please indicate period(s) off work: 9. Do you have any residual, ongoing effects or restrictions as a result of 9. Has your ability to perform daily If ‘yes', please provide dates and details: activities been restricted in any way? If ‘yes', please provide dates and details: 10. Is your treating doctor different from 10. Is your treating doctor different your usual doctor? from your usual doctor? If ‘yes', please complete the details below: If ‘yes', please complete the details below: Name of treating doctor Name of treating doctor See over > CARE Super Pty Ltd (Trustee) ABN 91 006 670 060 AFSL 235226. CARE Super (Fund) ABN 98 172 275 725 7. Questionnaires (continued) Questionnaire E – High blood pressure/raised Questionnaire F – Cysts, moles, sunspots or skin lesion questionnaire Only complete if you answered ‘yes' to question 5a of Only complete if you answered ‘yes' to question 5b of section 6b – Personal statement details.
section 6b – Personal statement details.
1. Name of condition 1. Please provide type: High blood pressure Raised cholesterol Melanoma Basal cell carcinoma 2. When were you first diagnosed with this condition? 3. Do you have any problems or complications resulting from this condition, e.g. heart disease, chest pain? 2. Location of growth(s) Face/head Back/shoulder ‘yes', please provide details: Chest/front Arm/leg 3. When was this? 4. Are you taking regular medication for this condition? 4. Was/were the growth(s) removed? If ‘yes', please provide details, including dosage: ‘yes', please complete below: When was it removed? 5. Blood pressure How many growths were removed? When was your last blood When was your last Method of removal: pressure reading? cholesterol reading? Frozen/burnt off Surgical/cut out 5. Was/were the growth(s) reported as cancerous Was it considered to be What was the result of your well controlled, e.g. less last cholesterol reading? ‘yes', were any further tests, investigations, treatments, follow up or re-excision required? ‘yes', please provide dates and details of further tests, 6. Is your treating doctor different from your usual doctor? investigations, treatments, follow up or re-excision: If ‘yes', please complete the details below: Name of treating doctor 6. Is your treating doctor different from your usual doctor? If ‘yes', please complete the details below: Name of treating doctor See over > Do NOT detach form CARE Super Pty Ltd (Trustee) ABN 91 006 670 060 AFSL 235226. CARE Super (Fund) ABN 98 172 275 725 CR/SUP/INS/APP/710.1 05/16 ISS8 7. Questionnaires (continued) Only complete if you Questionnaire G – Personal and medical details questionnaire answered ‘yes' to 1. When did you last consult a doctor? any part of question Within the last month 1 to 3 months ago 3 to 6 months ago 5c, d & e and/or 7 of section 6b – Personal 12 months to 2 years ago Over 2 years ago statement details.
a) What was the reason for this consultation? b) What was the result/outcome from your last consultation? (tick (✔) the appropriate box) Referral to specialist/health professional Tests conducted – results pending Ongoing treatment e.g. Ventolin inhaler Routine tests conducted – results all clear/normal All clear/normal/full recovery – no tests or prescribed treatment required (other than contraceptive and cold/flu medication) Not fully recovered yet c) Was the doctor/medical centre consulted, your usual doctor/medical centre? If you have been a patient of this doctor for less than 12 months, please provide details of your previous doctor/medical centres: Name of doctor 2. This question is for females only, otherwise please continue to question 3.
a) Are you currently pregnant? If ‘yes', what is the due date for your baby? b) Will you be returning to work in the same capacity as your current occupation, e.g. back to the same or greater hours within or at the end of your 12-month maternity leave? c) Have you ever had any complications with pregnancy or childbirth? (e.g. diabetes, ectopic pregnancy, pre-eclampsia & excluding elective caesarian or miscarriage in the first 15 weeks)? No Yes If ‘yes', please provide details and dates below? d) Have you ever had an abnormal result for any of the following tests? ii) Breast ultrasound If ‘yes', please provide details and dates below e) Have you ever had a breast lump or breast cyst or any other type of breast abnormality (even if you have not consulted a doctor)? If ‘yes', please provide details including dates and results of treatments.
f) Have you ever sought treatment for any condition of the ovary, uterus, endometrium or perineum? No Yes If ‘yes', please provide details including dates and results of treatments Please continue to question 3 over page > See over > CARE Super Pty Ltd (Trustee) ABN 91 006 670 060 AFSL 235226. CARE Super (Fund) ABN 98 172 275 725 7. Questionnaires (continued)Questionnaire G – Personal and medical details questionnaire (continued)3. Have you ever had, or sought advice or treatment, experienced symptoms or suffered from any of the following: Tick (✔) no or yes a) Asthma (other than childhood), chronic bronchitis, emphysema, recurrent pneumonia or any other lung complaint requiring hospitalisation in the last 5 years b) Chest pains, heart complaint, cardiomyopathy, heart murmur, palpitations or rheumatic fever c) Stroke, paralysis, neurological disorder, multiple sclerosis, muscular dystrophy or blood vessel disorder d) Alzheimer's, Parkinson's dementia or any other disorder of the brain e) Cancer, tumour or melanoma f) Thyroid, glandular, pituitary or pancreatic disorder g) Gastric or duodenal ulcer, persistent indigestion, gastro oesophageal reflux disease, Barrett's oesophagitis, irritable bowel or other bowel disorder (e.g. polyps, ulcerative colitis and Crohn's disease) h) Diabetes, gestational diabetes, insulin resistance or abnormal blood sugar i) Any disorder of the gall bladder or liver, including hepatitis B, C or fatty liver/raised liver function j) Varicose veins, haemorrhoids or hernia k) Disorder of the kidney, bladder or prostate (including raised PSA), blood in urine or kidney stones l) Epilepsy, fits of any kind, fainting episodes, dizziness or vertigo or recurring headaches or migraines m) Chronic fatigue syndrome, lethargy, sleep apnoea or any sleeping disorder including insomnia n) Arthritis, gout, osteoporosis, fibromyalgia, Repetitive Strain Injury (RSI) or any chronic pain o) Eczema, dermatitis, psoriasis or any other skin disorder p) Anaemia, leukaemia, haemophilia, haemochromatosis or any other blood disorder, embolism, thrombosis (DVT) or Factor V Leiden q) Any impairment of sight (other than corrected by glasses or lenses) or blurred vision r) Any impairment of hearing (including tinnitus, deafness, high frequency hearing loss) or speech s) Any sexually transmitted diseases t) Any other illness, injury, disease or disorder not mentioned above u) Other than those conditions mentioned above, are you taking any regular prescribed medication v) Have you undergone screening for diseases or conditions such as, but not limited to, bowel cancer or have you had a genetic test? w) Within the last 3 years, have you had an ECG, X-ray (excluding broken bones or joint strains), any abnormal blood test results, a genetic test or an ultrasound (other than for pregnancy)? x) Are you considering seeking medical advice, treatment, tests or surgery in the future? If you have answered ‘yes' to any of the above questions, please provide full details of each ‘yes' answer in section 8 – General health questionnaire on page 10.
Only complete if you Questionnaire H – Family history questionnaire answered ‘yes' to any part of question 8 of 1. Please complete the table below: section 6b – Personal Condition – if cancer please state type statement details.
2. Have you had or do you intend on having a genetic test? 3. What was the result of the genetic test? (tick (✔) the appropriate box) Have not been tested yet Positive (I have the gene) Negative (I do not have the gene) See over > Do NOT detach form CARE Super Pty Ltd (Trustee) ABN 91 006 670 060 AFSL 235226. CARE Super (Fund) ABN 98 172 275 725 CR/SUP/INS/APP/710.1 05/16 ISS8 8. General health questionnaire If you have answered Details for question number: ‘yes' to any part of question 3 a to x in 1. Name of injury, illness, section 7 – Questionnaire condition or tests? G, please complete the following general health 2. Date symptoms first 3. Date symptoms ceased 4. Are these symptoms singular, recurrent or 5. How often do/did you Please choose one of the following: daily, weekly, monthly, quarterly, half yearly, one off, other (please specify).
6. Severity of symptoms? Please choose one of the following: mild, moderate, severe, never had symptoms, symptoms ceased.
7. Did you take medication or have any other treatment for this condition? If ‘yes' please give details of the medication/ 8. Are you still on treatment, including medication? 9. Have you ever been off work as a result of this If ‘yes', please indicate the total time off work.
10. Do you have or have you had any residual, ongoing effects or restrictions as a result of this condition? 11. Have you ever had an x-ray, scan or blood test for this condition? 12. Is your treating doctor different from your usual If ‘yes', please provide the treating doctor's name and contact details.
See over > CARE Super Pty Ltd (Trustee) ABN 91 006 670 060 AFSL 235226. CARE Super (Fund) ABN 98 172 275 725 9a. Insurance duty of disclosure Before CareSuper as Trustee of the Fund enters into a life insurance contract in respect of the life of another person (a member), it has a duty to tell the insurer anything that it knows or could reasonably be expected to know that may affect the insurer's decision to provide the insurance and on what terms.
CareSuper has this duty of disclosure until the insurance is provided. CareSuper has the same duty before it extends, varies or reinstates the contract.
CareSuper does not need to tell the insurer anything that: Reduces the risk of the insurance, or Is common knowledge, or The insurer knows or should know as an insurer, or The insurer waives the duty to tell the insurer about.
If you as a member of CareSuper do not tell the insurer somethingIf you as the person whose life is to be insured as a member of CareSuper do not tell the insurer something that you know or could reasonably be expected to know that may affect the insurer's decision to provide the insurance and on what terms, this may be treated as a failure by CareSuper to comply with its duty of disclosure.
If CareSuper does not tell the insurer somethingIn exercising the following rights, the insurer may consider whether different types of cover can constitute separate contracts of life insurance. If the insurer does, it may apply the following rights separately to each type of cover.
If CareSuper does not tell the insurer anything they are required to and the insurer would not have provided the insurance if they had been told, the insurer may avoid the contract within three years of entering into it.
If the insurer chooses not to avoid the contract, it may at any time reduce the amount of insurance provided. This would be worked out using a formula that takes into account the premium that would have been payable if CareSuper had told the insurer everything it should have. However, if the contract has a surrender value or provides cover on death, the insurer may only exercise this right within three years of entering into the contract.
If the insurer chooses not to avoid the contract or reduce the amount of insurance provided, it may at any time vary the contract in a way that places the insurer in the same position it would have been in if CareSuper had told the insurer everything it should have. However, this right does not apply if the contract has a surrender value or provides cover on death.
If the failure to comply with the duty of disclosure is fraudulent, the insurer may refuse to pay a claim and treat the contract as if it never existed.
9b. Privacy of your personal information How CareSuper handles your personal information CareSuper collects your personal information to establish and administer your superannuation account. If you choose not to provide your personal information CareSuper may not be able to process your insurance application or administer your superannuation account, or provide you with some services offered by CareSuper.
I consent to the collection and use of my personal information by the Trustee to establish and administer my If you have any questions about your rights under the privacy legislation, please call CareSuper on 1300 360 149.
9c. Telephone underwriting The telephone underwriting facility reduces the need for follow-up information and medical reports, resulting in faster completion. I permit the insurer (CommInsure) to call me (the life to be insured) to clarify or gain further information regarding any matter pertaining to the assessment and processing of this application. I understand that the call will form part of my duty of disclosure as described in section 9a.
If ‘yes', I am contactable on the following number between the hours of (Note: They must be usual business hours Eastern Standard Time.) See over > Do NOT detach form CARE Super Pty Ltd (Trustee) ABN 91 006 670 060 AFSL 235226. CARE Super (Fund) ABN 98 172 275 725 CR/SUP/INS/APP/710.1 05/16 ISS8 .9d. Doctor's details In the event that we require further medical information, we require the contact details of your usual GP/doctor.
CareSuper you may ask to see the information the insurer holds about you and have it corrected if required. CareSuper's insurer for death, TPD and income protection is CommInsure. CommInsure is a registered business of The Colonial Mutual Life Assurance Society Limited ABN 12 004 021 809 By providing these details and signing this form, I give CareSuper permission to contact my doctor above in relation to AFSL 235035 (CMLA). my health information.
9e. Sign this form I have read the duty of disclosure in this insurance application and I am aware of the consequences of The answers to all the questions and the declarations on this Personal Statement are true and correct.
I understand that the duty of disclosure continues I have not withheld any information which may affect after I have completed this statement until my the insurer's decision to provide insurance.
application for cover has been accepted by the insurer in writing.
I acknowledge that the answers I have provided, together with any special conditions, will form the basis Any increase in insurance of the contract of insurance.
cover under a new The insurer to refer any statements that have been I have read and understand the obligations outlined member option will made in connection with my application for cover in the duty of disclosure in section 9a on page 11.
not be payable if the and any medical reports to other entities involved death, terminal illness or in providing or administering the insurance (for I have read and understood ‘privacy of your personal information' in section 9b on page 11. I acknowledge disablement is caused example reinsurers, medical consultants, legal and consent to the use and disclosure of my personal directly or indirectly by an information as detailed in that section.
illness, injury or medical The insurer and any person appointed by the condition relating to a insurer to obtain information on my medical l have read and understood the CareSuper Member Guide PDS and the incorporated Insurance Guide. pre-existing condition that claims and financial history from the Insurance I acknowledge that no cover commences until this occurred during the 5 Reference Association and any other body holding application is accepted by the insurer (CommInsure). years before applying for information on me.
I acknowledge that if I do not complete this application the increased cover. Any hospital, doctor or other person who has correctly, or I do not sign and date this form, my treated or examined me to give to the insurer any application will be invalid and will not be considered information on my illness or injury, medical history, by the insurer.
consultation, prescription or treatment or copies of all hospital or medical reports.
Please ensure you initial A photocopy of this authorisation is as valid as the any errors and amendments original. I agree to provide further medical authorities made on this form.
You must sign and date this form.
CareSuper member number (if known) Member's signature Date (DD/MM/YYYY) Return this completed form to:CareSuper GPO Box 1923 Melbourne VIC 3001 Parramatta NSW 2124 For more information call For more information the CareSuperLine call the CareSuperLine CARE Super Pty Ltd (Trustee) ABN 91 006 670 060 AFSL 235226. CARE Super (Fund) ABN 98 172 275 725
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MAYFAIR CLINICAL EDUCATION & RESEARCH CENTRE, Mohan Mill Compound, Ghodbunder Road, Thane-400 607. Document No MCERC/REPTCLTR/OXY/1205/001 Study Identifier: Mfair/oxy/200506 REPORT FOR HUMAN CLINICAL TRIAL PHASE III TO STUDY THE SAFETY AND EFFECTIVENESS OF OXY-POWDER® DOCUMENT NO.: MCERC/REPT-CLTR/OXY/1205/001